Sexually transmitted infections associated syndromes assisted in the primary health care in Northeast, Brazil

Prevention and control of sexually transmitted infections (STI) are challenges to be overcome all around the world and have gained importance again in public health context after evidences of their effects as cofactors for HIV transmission [1]. It is estimated that more than 448 million new cases of curable sexually transmitted infections (syphilis, gonorrhea, chlamydia and trichomoniasis) occur annually throughout the world [2], and if viral infections (human papillomaviruses, herpes simplex virus and HIV) were considered, this estimate would be substantially higher [3]. It is a problem that concerns the international community due to its serious implications for individual and collective health [3, 4].

In Brazil, the epidemiological data on STI are scarce and the only ones which the notification is compulsory are Aids, HIV in pregnant women and exposed children, syphilis and urethral discharge syndrome in men [5]. Although the notification of these infections is compulsory, Brazilian health services do not perform it systematically, what causes an unawareness of the real magnitude of the problem and makes it difficult to develop strategies for prevention and control.

The Ministry of Health (MH) of Brazil, aiming to know the prevalence of these pathologies in general population (pregnant women and industry workers) and in vulnerable populations (people attending health clinics for care for STI), performed a multi-centered study in six Brazilian capitals. It identified prevalence of curable STI (syphilis, gonorrhea and chlamydia) in 13.5 % of pregnant women, 6.2 % of industry workers and 19.7 % of people attending health clinics for care for STI [6].

The data found in this study guarantee what is recommended by international institutions [7], i.e., that prevalence higher than 5% of curable STI imposes an enormous burden of morbidity in these capitals and probably in Brazil as well, reinforcing evidences that point out to failures in its prevention and control actions [6, 8].

Concerning preventive actions, the predominant mode of transmission of STI is sexual, same as HIV, however, in some countries, there’s a great number of people and financial efforts for actions aimed at aids [9]. This can be noticed in Brazil through the efforts to reduce the vertical transmission of HIV when compared to the congenital syphilis [10]. On the other hand, epidemiological studies have acknowledged the treatment for STI as an important strategy to reduce the transmission of HIV, especially in countries where it is a recent epidemic [11].

Traditionally, STI were treated with an etiologic and clinical approach and both methods presented limitations. Then, there was the need to test other tools, what resulted in the development of the management of STI – Associated Syndromes through the use of flowcharts [12]. This strategy is recommended for places with few financial resources and personnel and with a poor access to laboratory tests.

The difficulties in the etiologic assessment of syndromes in Brazil led the Ministry of Health to recommend, from 1993, the management of STI – Associated Syndromes through the use of flowcharts. These ones were validated [13] and, due to limitations in the diagnosis of vaginal discharge syndrome [14], its flowchart has been reformulated in attempt to improve the positive predictive value. It also recommends that professionals assisting STI – Associated Syndromes shall make use of the Venereal Disease Research Laboratory test (VDRL), serology for HIV and most recently for Hepatitis B and C [14].

Studies on STI – Associated Syndromes in primary health care have not been performed in Brazil. There is a lack of information to help characterize the demand of people assisted in these services, and it makes it difficult to know the most prevalent syndromes and to identify the cases of syphilis and HIV.

The lack of visibility of the problem of STI and of the strategies adopted for its prevention and control may contribute for its non-inclusion in the primary health care system in Brazil. Generally, the health services are not properly prepared for this demand, maybe due to the lack of qualified professionals or organizational and operational conditions of these services.

Thus, this study aimed to analyze the cases of STI – Associated Syndromes assisted in a primary health care center in a city in Northeast Brazil, associating them with socio-demographic and behavioral variables and with the results of the VDRL and Anti-HIV tests.

The most frequent syndrome was vaginal discharge and/or cervicitis (44.5%), followed by genital wart (42.2%), urethral discharge (5.2%), genital ulcer (4.8%) and pelvic pain (1.4%). Figure 1 shows the annual distribution of STI – Associated Syndromes according to the consultations in the unit from 1999 to 2008. In the first three years the most prevalent cases were vaginal discharge and/or cervicitis, which have decreased along the years. It is possible to notice that the number of people with genital wart who attended the unit stands out among the other syndromes and it doesn’t change along the years.

The multiple regression analysis showed a significant association between genital ulcer and the variables sex (OR = 2.67; CI 95% 1.99-3.58) and schooling (OR = 1.33; CI 95% 1.00-1.75), and between genital wart and sex (OR = 3.92; CI 95% 3.36-4.57), age (OR = 1.81; CI 95% 1.59-2.07) and schooling (OR = 1.75; CI 95% 1.54-1.99) (Table 2).

It is important to add that the unit where this study took place was the first one to include the health care services for STI – Associated Syndromes in Fortaleza, which means that it required organization, a training program with all the professionals for the proper management of cases of STI, reception and counseling, and also the availability of inputs and medicines, which might have contributed for a better performance of the health team during the assistance of cases.

It was noticed that most people who looked for care were women, people within their reproductive age and with a low schooling. In Brazil, despite the efforts to improve actions for women’s health, the primary health care services are still directed to infant-maternal care [18]. In Fortaleza, the care for STI was implemented in 1999 and most of the people who looked for care were women, which may be the reason for a large number of cases of vaginal discharge syndrome in the first three years after its implementation.

A low percentage of men looked for care in this unit. This low demand may be related to men’s difficulty to access health care services [19], sociocultural and gender peculiarities [18, 20] and the difficulties for health professionals to properly manage cases, once they represent barriers to be overcome in order to effectively control STI in Brazil. Actions directed to men’s health are still being implemented in the country [21].

It is important to highlight the presence of children among the people who looked for care and its implications when it derives from sexual abuse [22]. In Brazil, despite the policies aimed at prevention and treatment of harms resulting from sexual abuse [23], there are many barriers for the management of these cases such as the victims themselves and their families, the professionals and mainly the lack of an organized care system for this demand.

There was a higher rate of vaginal discharge syndrome and/or cervicitis among the cases. Although vaginal discharge is not necessarily related to a STI, it is one of the most frequent reasons for looking for care in of sexually transmitted diseases (STD) services in Brazil [6] and evidences show that it can increase the risk to acquire HIV [24, 25], what reinforces the importance of the inclusion of its management in primary health care. In Brazil, this flowchart was validated and improved in attempt to increase its predictive value in the diagnosis of cervicovaginal diseases [13].

The analysis of the syndromes that occur in both men and women showed that genital wart and ulcer were most prevalent among men, a result that is similar to the one found in a study performed in Brazil [6]. Considering this and the fact that ulcers have been found to be associated with increased risk of HIV transmission and genital warts to be powerful predictors for Human Papillomavirus (HPV) [6], there is an important need for treatment and/or follow-up of people, especially men, in primary health care. However, there are many draw-backs for the management of cases in health services due to operational conditions, lack of training programs and professionals’ resistance to perform the treatment.

Although most of the people have reported having only one sexual partner in the past three months, the genital wart and ulcer syndromes were most prevalent in people with two or more partners. It’s worth saying that, although most of the people were women, men were the ones who reported having more sexual partners, confirming the findings of other studies in Brazil which report that the exchange of sexual partners is more common among men [26]. Despite the possibility of information bias, which certainly limited the analysis of this variable, we consider that this finding can represent the demand of people who look for care in the primary health care in Brazil, mainly women who do not run an imminent risk of STI and HIV but are vulnerable to them [26, 27].

We found a high prevalence of reactive VDRL (8.2%), higher than the one found in a study conducted with people who looked for care in STD clinics in Brazil [6]. This was probably due to the unavailability of confirmatory tests for the diagnosis of syphilis in the primary health care. Moreover, the VDRL test is considered a powerful predictor of syphilis, even in cases with low titration [28], and its use in public health is internationally recommended for places where the diagnosis confirmation is not available. For this reason, it is recommended that all people with reactive VDRL shall be treated for syphilis [3].

The identification of 1.3% of reactive serology for HIV among people with STI – Associated Syndromes calls the attention to the importance of tests for people with genital syndromes. In Brazil, the access to anti-HIV testing is provided only for pregnant or parturient women and for people who attend Testing and Counseling Centers and blood banks [29].

It was observed a great use of VDRL and HIV tests, which might have happened due to the unit management system. The unit collects blood samples right after the consultation, with a pre and post-test counseling. The high percentage of people who return to the unit points out to a good acceptance of its system and can be considered an important indicator of the good quality of its services.

However, it’s worth saying that the lack of records of confirmatory tests for syphilis, data on notification of partners and also on patients’ sexual orientation has limited the analysis of this study because it hindered the gathering of further information on the people assisted and their association with the variables analyzed.

It is important to say that the care for STI – Associated Syndromes in primary health care requires motivated and trained personnel, availability of medicines, accessible and acceptable health services and also an improvement in quality of records. Such records could provide information for a better understanding of the demand of people with STI – Associated Syndromes assisted in the unit and contribute to the development of feasible prevention strategies.

This study enabled to identify that vaginal discharge was the main STI – Associated Syndrome assisted in primary health care followed by genital wart. The high prevalence of genital wart justifies the implementation of efforts for a proper follow-up of these cases. Men presented more wart and genital ulcer syndromes and reported having more sexual partners, calling the attention to the need to improve their access and inclusion in health activities developed in the primary health care in Brazil.

Elani Graça Ferreira Cavalcante, MS, Secretary of the State of Ceará.

Maria Alix Leite Araujo, PhD, Professor, University of Fortaleza.

Marli Teresinha Gimeniz Galvão, PhD, Professor, Federal University of Ceará.

Heber José de Moura, PhD, Professor, University of Fortaleza.

Ana Paula Soares Gondim, PhD, Professor, University of Fortaleza.

Raimunda Magalhães da Silva, PhD, Professor, University of Fortaleza.